Stop Scratching and Cut...
In his presentation to the Central Surgical Association titled "Why Johnny cannot operate", Dr Bell outlines the problems and the lack of readiness of surgeons qualifying for a surgical career. A key finding from a survey of surgeons completing their residency was a widespread variability in number of operations completed.
The next decade will be a great challenge for the profession- as patient demand increases, there is a looming shortage of supply. There is a need to increase residency programs by 20% but more importantly the very mechanism by which surgical training is delivered needs to change.
Learning in the OR?
Learning to operate in the OR is difficult as a resident. Although,I had attended dissection, practiced my suturing technique on chicken breasts and bananas - when you make your first incision its an nerve wracking experience.
Operating with a senior observing your every step and challenging you at every decision creates even more anxiety in even the bravest surgical trainees.
I remember the day I started overcoming my nerves- a great mentor- asked me "what are you scared of?" whilst i was dissecting through a layer- "stop scratching and cut". It was at this point I realised that anatomically there was nothing that I would injure here and I proceeded bravely.
The thing with surgery is its abstract until you apply it- you can learn anatomy, and read through the principles- but until you are applying the principles its abstract... Learning to operate is therefore a union of the cognitive and the technical.
I often make the quote that cognitive decision making accounts for 75% of an operation and technical ability is 25%. I get questioned on where that is evidenced in the literature and what does this mean. Practically, the anecdote is an experienced surgeon faced with a challenging surgical scenario rarely does he feel anxious about his technical ability, the challenge is often a cognitive procedural decision.
That said technical ability is important. Not having to think about how to do with your hands reduces the cognitive load and allows focus on completing tasks.
What can be learned outside of the OR?
To answer this question I often rephrase it to- What should a surgeon know before entering the OR? a surgeon needs to be safe in the operating room. Safety- entails granular step-by-step knowledge of a procedure, of the anatomy, of the risks, and the key decision making points.
Demands of a simulation?
The role of any simulation program should be to enable surgeons to achieve a level of competency that deems him/her safe in the OR. Currently there is no specific evidence in the literature defining what that level entails- it remains the decision of a senior surgeon. Thus a simulators function can be categorised into two global themes:
1) Deliver learning that translates into competent practice in surgery
2) Plot learning with an identifiable benchmark of competence
In his paper Dr Bell makes 8 recommendations- one of the most powerful is the need to use simulation technology to facilitate acquisition of expertise outside of the OR. So powerful is this cry for simulation that Dr Bell suggest that a "national multidisciplinary consortium of universities and industries to approach the U.S. congress for a multimillion, if not billion, dollar program to create the next generation of simulation". The greatest challenge as ever beyond funding is delivery of a valid solution on a global scale.
